Universal safe procedure of laparoscopic cholecystectomy standardized by exposing the inner layer of the subserosal layer (with video)
Universal safe procedure of laparoscopic cholecystectomy standardized by exposing the inner layer of the subserosal layer (with video)
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DOI：
10.1002/jhbp.382
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发表时间：
2016-09-01
影响因子：
3
通讯作者：
Umezawa, Akiko
中科院分区：
文献类型：
--
作者：
Honda, Goro;Hasegawa, Hiroshi;Umezawa, Akiko
对安全性关键观点的不正确方法可能导致胆管和/或血管损伤。然而，在以前的报告中，只有浅表解剖特征被提议作为安全启动腹腔镜胆囊切除术（LC）的手术标志。因此，我们提出了一种新的外科解剖学定义的胆囊壁，其中的浆膜下（SS）层分为内层的SS（SS-内）层的血管和纤维组织组成，和外层的SS（SS-外）层的丰富的脂肪组织组成。通过在安全区域暴露后沿SS内层沿着解剖胆囊，即使在胆囊炎病例中也可避免胆管和/或血管损伤。此外，对这种外科解剖结构的认识揭示了几个方面。在胆囊炎伴严重纤维化改变的病例中，不可能通过沿着SS内层解剖完成LC，导致放弃常规LC。急性胆囊炎引起的肝床脓肿通常形成于胆囊壁的外层，因此，胆囊很容易切除。在圆顶向下技术中，右肝管受到全层解剖的威胁，其中SS外层也被去除。建议的程序应成为信用证的普遍标准。
An incorrect approach to the critical view of safety can cause bile duct and/or vascular injury. However, only superficial anatomical features have been proposed as surgical landmarks to initiate laparoscopic cholecystectomy (LC) safely in previous reports. Accordingly, we have proposed a novel surgical anatomical definition of the gallbladder wall, in which the subserosal (SS) layer is divided into the inner layer of the SS (SS-Inner) layer consisting of vasculature and fibrous tissue, and the outer layer of the SS (SS-Outer) layer consisting of abundant fat tissue. By dissecting the gallbladder along the SS-Inner layer after exposure at a safe region, bile duct and/or vascular injury can be avoided, even in cholecystitis cases. Furthermore, recognition of this surgical anatomy reveals several aspects. In cholecystitis cases associated with severe fibrotic change, completion of LC by dissecting along the SS-Inner layer is impossible, resulting in abandonment of regular LC. An abscess in the liver bed associated with acute cholecystitis usually forms in the SS-Outer layer, thus, the gallbladder can be dissected easily. In the dome-down technique, the right hepatic duct is endangered by whole-layer dissection, in which the SS-Outer layer is also removed. The proposed procedure should become the universal standard for LC.